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ID

19010

Beschrijving

Hospital Routine Documentation Subform at the University Hospital Muenster. Original Form name: AN MS MEDD Anamnese KU NTX.

Trefwoorden

D009398

Körperliche Untersuchung

Nierentransplantation

Routine documentation

Anamnesenerhebung

Ultrasonography

15-11-16 15-11-16 -
30-11-16 30-11-16 -

Geüploaded op

30 november 2016

DOI

Voor een aanvraag inloggen.

Licentie

Creative Commons BY-NC 3.0

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AN MS MEDD Anamnese KU NTX University Hospital Muenster (UKM) Subform

model
Details

AN MS MEDD Anamnese KU NTX University Hospital Muenster (UKM) Subform

1 Formulieren

StudyEvent: ODM
1. AN MS MEDD Anamnese KU NTX University Hospital Muenster (UKM) Subform

Name

Type

Description | Question | Decode (Coded Value)

Datatype

Alias

General information

Item Group

Allgemeine Angaben

C1508263 (UMLS CUI-1)
C1955348 (UMLS CUI-2)
C0587474 (UMLS CUI-3)
C0022671 (UMLS CUI-4)

Examiner

Item

Untersucher

text

C0025082 (UMLS CUI [1,1])
C0025084 (UMLS CUI [1,2])
C0031809 (UMLS CUI [1,3])

Date of medical history taking

Item

Vorstellung vom

date

C0034927 (UMLS CUI [1,1])
C0025084 (UMLS CUI [1,2])
C0011008 (UMLS CUI [1,3])

Mode of medical history taking

Item

Erhebungsmodus

text

C0025084 (UMLS CUI [1,1])
C0332307 (UMLS CUI [1,2])

Current medical history

Item

Jetzige Anamnese

text

C0262926 (UMLS CUI [1])

Vegetative anamnesis and management of risk factors

Item Group

Vegetative Anamnese und Risikofaktorenmanagement

C0262926 (UMLS CUI-1)
C0037088 (UMLS CUI-2)
C0035648 (UMLS CUI-3)
C0376636 (UMLS CUI-4)

Height

Item

Größe

float

C0005890 (UMLS CUI [1])

Weight

Item

Gewicht

float

C0005910 (UMLS CUI [1])

BMI

Item

BMI

text

C1305855 (UMLS CUI [1])

Change in weight

Item

Gewichtsveränderung

boolean

C0005911 (UMLS CUI [1])

Change in weight (specification)

Item

Gewichtsveränderung (wenn ja, bitte beschreiben)

text

C0005911 (UMLS CUI [1,1])
C2348235 (UMLS CUI [1,2])

Amount of liquid consumed (per day)

Item

Trinkmenge (pro Tag)

float

C0429791 (UMLS CUI [1])

Amount of liquid consumed (specification)

Item

Trinkmenge (Beschreibung)

text

C0429791 (UMLS CUI [1])

Diuresis (per day)

Item

Eigendiurese (pro Tag)

float

C0012797 (UMLS CUI [1])

Diuresis

Item

Eigendiurese

text

C0012797 (UMLS CUI [1])

Hypertension: Mean systolic blood pressure

Item

Hypertonus: Mittlerer sys. RR

integer

C0020538 (UMLS CUI [1])
C0428886 (UMLS CUI [2,1])
C0871470 (UMLS CUI [2,2])

Hypertension: systolic

Item

Hypertonus: systolisch

text

Hypertension: Mean diastolic blood pressure

Item

Hypertonus: Mittlerer diast. RR

integer

C0020538 (UMLS CUI [1])
C0428886 (UMLS CUI [2,1])
C0428883 (UMLS CUI [2,2])

Hypertension: diastolic

Item

Hypertonus: diastolisch

text

C0428883 (UMLS CUI [1])
C0020538 (UMLS CUI [2])

Hypertension: 24 h RR (syst/diast)

Item

Hypertonus: 24 h RR (syst/diast)

text

C0451604 (UMLS CUI [1])
C0020538 (UMLS CUI [2])

Hypertension: Date of 24 h RR measurement

Item

Hypertonus: Datum 24 h RR

date

C0451604 (UMLS CUI [1,1])
C0011008 (UMLS CUI [1,2])
C0020538 (UMLS CUI [2])

Hypertension: Comments 24 h RR

Item

Hypertonus: Bemerkungen 24 H RR

text

C0451604 (UMLS CUI [1,1])
C0947611 (UMLS CUI [1,2])
C0020538 (UMLS CUI [2])

Fever

Item

Fieber

boolean

C0015967 (UMLS CUI [1])

Fever (specification)

Item

Fieber (wenn ja, bitte beschreiben)

text

C0015967 (UMLS CUI [1])

Stool

Item

Stuhlverhalten

boolean

C1290944 (UMLS CUI [1,1])
C0015733 (UMLS CUI [1,2])

Stool (specification)

Item

Stuhlverhalten (wenn ja, bitte beschreiben)

text

C1290944 (UMLS CUI [1,1])
C0015733 (UMLS CUI [1,2])

Micturition

Item

Miktion

boolean

C0042034 (UMLS CUI [1,1])
C0542565 (UMLS CUI [1,2])

Micturition (specification)

Item

Miktion (wenn ja, bitte beschreiben)

text

C0042034 (UMLS CUI [1,1])
C0542565 (UMLS CUI [1,2])

Nocturia

Item

Nykturie

boolean

C0028734 (UMLS CUI [1])

Nocturia (specification)

Item

Nykturie (wenn ja, bitte beschreiben)

text

C0028734 (UMLS CUI [1])

Coughing

Item

Husten

boolean

C0010200 (UMLS CUI [1])

Coughing (specification)

Item

Husten (wenn ja, bitte beschreiben)

text

C0010200 (UMLS CUI [1])

Sputum

Item

Auswurf

boolean

C0038056 (UMLS CUI [1])

Sputum (specification)

Item

Auswurf (wenn ja, bitte beschreiben)

text

C0038056 (UMLS CUI [1])

Shortness of breath

Item

Luftnot

boolean

C0013404 (UMLS CUI [1])

Shortness of breath (specification)

Item

Luftnot (wenn ja, bitte beschreiben)

text

C0013404 (UMLS CUI [1])

Edema

Item

Ödeme

boolean

C0013604 (UMLS CUI [1])

Edema (specification)

Item

Ödeme (wenn ja, bitte beschreiben)

text

C0013604 (UMLS CUI [1])

Night sweats

Item

Nachtschweiß

boolean

C0028081 (UMLS CUI [1])

Night sweats (specification)

Item

Nachtschweiß (wenn ja, bitte beschreiben)

text

C0028081 (UMLS CUI [1])

Joint trouble

Item

Gelenkbeschwerden

boolean

C0022408 (UMLS CUI [1])

Joint trouble (specification)

Item

Gelenkbeschwerden (wenn ja, bitte beschreiben)

text

C0022408 (UMLS CUI [1])

Signs of vasculitis

Item

Vasculitiszeichen

boolean

C0042384 (UMLS CUI [1,1])
C0037088 (UMLS CUI [1,2])

Signs of vasculitis (specification)

Item

Vasculitiszeichen (wenn ja, bitte beschreiben)

text

C0042384 (UMLS CUI [1,1])
C0037088 (UMLS CUI [1,2])

Appetite

Item

Appetit

boolean

C0003618 (UMLS CUI [1])

Appetite (specification)

Item

Appetit (wenn ja, bitte beschreiben)

text

C0003618 (UMLS CUI [1])

Sleep

Item

Schlaf

boolean

C0037313 (UMLS CUI [1])

Sleep (specification)

Item

Schlaf (wenn ja, bitte beschreiben)

text

C0037313 (UMLS CUI [1])

Nicotine

Item

Nikotin

boolean

C0543414 (UMLS CUI [1])

Nicotine: packets per day

Item

Nikotin: Schachteln/Tag

float

C0543414 (UMLS CUI [1,1])
C2348070 (UMLS CUI [1,2])
C0560663 (UMLS CUI [2])

Nicotine: duration of consumption (years)

Item

Nikotin: Konsum seit (Jahre)

float

C0543414 (UMLS CUI [1,1])
C0449238 (UMLS CUI [1,2])

Nicotine: Ex-smoker

Item

Nikotin: Ex-Raucher

boolean

C0543414 (UMLS CUI [1])
C0337671 (UMLS CUI [2])

Nicotine: Ex-smoker since (years)

Item

Nikotin: Ex-Raucher seit (Jahre)

float

C0543414 (UMLS CUI [1])
C0337671 (UMLS CUI [2,1])
C0449238 (UMLS CUI [2,2])

Nicotine (specification)

Item

Nikotin (sonstiges)

text

C0543414 (UMLS CUI [1,1])
C0205394 (UMLS CUI [1,2])

Alcohol

Item

Alkohol

boolean

C0038586 (UMLS CUI [1])
C0085762 (UMLS CUI [2])

Alcohol (specification)

Item

Alkohol (wenn ja, bitte beschreiben)

text

C0038586 (UMLS CUI [1])
C0085762 (UMLS CUI [2])

Hypercholesterolemia

Item

Hypercholesterinämie

boolean

C0020443 (UMLS CUI [1])

Hypercholesterolemia (specification)

Item

Hypercholesterinämie (wenn ja, bitte beschreiben)

text

C0020443 (UMLS CUI [1])

Diabetes

Item

Diabetes

boolean

C0011849 (UMLS CUI [1])

Diabetes (specification)

Item

Diabetes (wenn ja, bitte beschreiben)

text

C0011849 (UMLS CUI [1])

Calcium/phosphate balance

Item

Calcium/Phosphat-Haushalt

boolean

C0013831 (UMLS CUI [1,1])
C0201925 (UMLS CUI [1,2])
C0523826 (UMLS CUI [1,3])

Calcium/phosphate balance (specification)

Item

Calcium/Phosphat-Haushalt (wenn ja, bitte beschreiben)

text

C0013831 (UMLS CUI [1,1])
C0201925 (UMLS CUI [1,2])
C0523826 (UMLS CUI [1,3])

Other risk factors

Item

Sonstige Risikofaktoren

boolean

C0035648 (UMLS CUI [1,1])
C0205394 (UMLS CUI [1,2])

Other risk factors (specification)

Item

Sonstige Risikofaktoren (wenn ja, bitte beschreiben)

text

C0035648 (UMLS CUI [1,1])
C0205394 (UMLS CUI [1,2])

Clinical examination

Item Group

Klinische Untersuchung

C0031809 (UMLS CUI-1)

General findings/skin

Item

Allgemeinbefund/Haut

boolean

C0455205 (UMLS CUI [1])

General findings/skin (specification)

Item

Allgemeinbefund/Haut (wenn ja, bitte beschreiben)

text

C0455205 (UMLS CUI [1])

Head

Item

Kopf

boolean

C0018670 (UMLS CUI [1,1])
C0243095 (UMLS CUI [1,2])
C0031809 (UMLS CUI [1,3])

Head (specification)

Item

Kopf (wenn ja, bitte beschreiben)

text

C0018670 (UMLS CUI [1,1])
C0243095 (UMLS CUI [1,2])
C0031809 (UMLS CUI [1,3])

Neck

Item

Hals

boolean

C0027530 (UMLS CUI [1,1])
C0243095 (UMLS CUI [1,2])
C0031809 (UMLS CUI [1,3])

Neck (specification)

Item

Hals (wenn ja, bitte beschreiben)

text

C0027530 (UMLS CUI [1,1])
C0243095 (UMLS CUI [1,2])
C0031809 (UMLS CUI [1,3])

Thorax

Item

Thorax

boolean

C0817096 (UMLS CUI [1,1])
C0243095 (UMLS CUI [1,2])
C0031809 (UMLS CUI [1,3])

Thorax (specification)

Item

Thorax (wenn ja, bitte beschreiben)

text

C0817096 (UMLS CUI [1,1])
C0243095 (UMLS CUI [1,2])
C0031809 (UMLS CUI [1,3])

Lungs

Item

Lunge

boolean

C2228454 (UMLS CUI [1,1])
C0243095 (UMLS CUI [1,2])

Lungs (specification)

Item

Lunge (wenn ja, bitte beschreiben)

text

C2228454 (UMLS CUI [1,1])
C0243095 (UMLS CUI [1,2])

Cardiovascular system

Item

Herz- und Gefäßsystem

boolean

C0007226 (UMLS CUI [1,1])
C0243095 (UMLS CUI [1,2])
C0031809 (UMLS CUI [1,3])

Cardiovascular system (specification)

Item

Herz- und Gefäßsystem (wenn ja, bitte beschreiben)

text

C0007226 (UMLS CUI [1,1])
C0243095 (UMLS CUI [1,2])
C0031809 (UMLS CUI [1,3])

Heart

Item

Cor

boolean

C0018787 (UMLS CUI [1,1])
C0243095 (UMLS CUI [1,2])
C0031809 (UMLS CUI [1,3])

Heart (specification)

Item

Cor (wenn ja, bitte beschreiben)

text

C0018787 (UMLS CUI [1,1])
C0243095 (UMLS CUI [1,2])
C0031809 (UMLS CUI [1,3])

Pulse status

Item

Pulsstatus

boolean

C0558829 (UMLS CUI [1])

Pulse status (specification)

Item

Pulsstatus (wenn ja, bitte beschreiben)

text

C0558829 (UMLS CUI [1])

Pulse status: Upper limb N.A.D.

Item

Pulsstatus: Obere Extremität o.p.B.

boolean

C0558829 (UMLS CUI [1,1])
C1140618 (UMLS CUI [1,2])

Pulse status: Right carotid artery

Item

Pulsstatus: Carotis rechts

text

C1096529 (UMLS CUI [1,1])
C0226086 (UMLS CUI [1,2])

Pulse status: Left carotid artery

Item

Pulsstatus: Carotis links

text

C1096529 (UMLS CUI [1,1])
C0226087 (UMLS CUI [1,2])

Pulse status: Right radial artery

Item

Pulsstatus: Radialis rechts

text

C2363059 (UMLS CUI [1,1])
C0226438 (UMLS CUI [1,2])

Pulse status: Left radial artery

Item

Pulsstatus: Radialis links

text

C2363059 (UMLS CUI [1,1])
C0226439 (UMLS CUI [1,2])

Pulse status: Lower limb N.A.D.

Item

Pulsstatus: Untere Extremität o.p.B.

boolean

C0558829 (UMLS CUI [1])

Pulse status: Right femoral artery

Item

Pulsstatus: Femoralis rechts

text

C2228442 (UMLS CUI [1,1])
C0226447 (UMLS CUI [1,2])

Pulse status: Left femoral artery

Item

Pulsstatus: Femoralis links

text

C2228442 (UMLS CUI [1,1])
C0226448 (UMLS CUI [1,2])

Pulse status: Right popliteal artery

Item

Pulsstatus: Poplitea rechts

text

C0232151 (UMLS CUI [1,1])
C0226462 (UMLS CUI [1,2])

Pulse status: Left popliteal artery

Item

Pulsstatus: Poplitea links

text

C0232151 (UMLS CUI [1,1])
C0226463 (UMLS CUI [1,2])

Pulse status: Right posterior tibial artery

Item

Pulsstatus: Tibialis posterior rechts

text

C1720310 (UMLS CUI [1,1])
C0226474 (UMLS CUI [1,2])

Pulse status: Left posterior tibial artery

Item

Pulsstatus: Tibialis posterior links

text

C1720310 (UMLS CUI [1,1])
C0226475 (UMLS CUI [1,2])

Pulse status: Right dorsalis pedis artery

Item

Pulsstatus: Dorsalis pedis rechts

text

C1706488 (UMLS CUI [1,1])
C0834665 (UMLS CUI [1,2])

Pulse status: Left dorsalis pedis artery

Item

Pulsstatus: Dorsalis pedis links

text

C1706488 (UMLS CUI [1,1])
C0834666 (UMLS CUI [1,2])

Blood pressure right

Item

Blutdruck rechts

text

C0005823 (UMLS CUI [1,1])
C0205090 (UMLS CUI [1,2])

Blood pressure left

Item

Blutdruck links

text

C0005823 (UMLS CUI [1,1])
C0205091 (UMLS CUI [1,2])

Transplant

Item

Transplantat

boolean

C0478647 (UMLS CUI [1,1])
C0243095 (UMLS CUI [1,2])
C0031809 (UMLS CUI [1,3])

Transplant (specification)

Item

Transplantat (wenn ja, bitte beschreiben)

text

C0478647 (UMLS CUI [1,1])
C0243095 (UMLS CUI [1,2])
C0031809 (UMLS CUI [1,3])

Abdomen

Item

Abdomen

boolean

C0000726 (UMLS CUI [1,1])
C0243095 (UMLS CUI [1,2])
C0031809 (UMLS CUI [1,3])

Abdomen (specification)

Item

Abdomen (wenn ja, bitte beschreiben)

text

C0000726 (UMLS CUI [1,1])
C0243095 (UMLS CUI [1,2])
C0031809 (UMLS CUI [1,3])

Genitourinary system / rectum

Item

Urogenitalsystem / Rektum

boolean

C0042066 (UMLS CUI [1,1])
C0243095 (UMLS CUI [1,2])
C0031809 (UMLS CUI [1,3])
C0034896 (UMLS CUI [2,1])
C0243095 (UMLS CUI [2,2])
C0031809 (UMLS CUI [2,3])

Genitourinary system / rectum (specification)

Item

Urogenitalsystem / Rektum (wenn ja, bitte beschreiben)

text

C0042066 (UMLS CUI [1,1])
C0243095 (UMLS CUI [1,2])
C0031809 (UMLS CUI [1,3])
C0034896 (UMLS CUI [2,1])
C0243095 (UMLS CUI [2,2])
C0031809 (UMLS CUI [2,3])

Limbs/edema

Item

Extremitäten/Ödem

boolean

C0015385 (UMLS CUI [1,1])
C0243095 (UMLS CUI [1,2])
C0031809 (UMLS CUI [1,3])
C0013604 (UMLS CUI [2,1])
C0243095 (UMLS CUI [2,2])
C0031809 (UMLS CUI [2,3])

Limbs/edema (specification)

Item

Extremitäten/Ödem (wenn ja, bitte beschreiben)

text

C0015385 (UMLS CUI [1,1])
C0243095 (UMLS CUI [1,2])
C0031809 (UMLS CUI [1,3])
C0013604 (UMLS CUI [2,1])
C0243095 (UMLS CUI [2,2])
C0031809 (UMLS CUI [2,3])

Spine

Item

Wirbelsäule

boolean

C0037949 (UMLS CUI [1,1])
C0243095 (UMLS CUI [1,2])
C0031809 (UMLS CUI [1,3])

Spine (specification)

Item

Wirbelsäule (wenn ja, bitte beschreiben)

text

C0037949 (UMLS CUI [1,1])
C0243095 (UMLS CUI [1,2])
C0031809 (UMLS CUI [1,3])

Nervous system and psyche

Item

Nervensystem und Psyche

boolean

C0027763 (UMLS CUI [1,1])
C0243095 (UMLS CUI [1,2])
C0031809 (UMLS CUI [1,3])
C0846574 (UMLS CUI [2,1])
C0243095 (UMLS CUI [2,2])

Nervous system and psyche (specification)

Item

Nervensystem und Psyche (wenn ja, bitte beschreiben)

text

C0027763 (UMLS CUI [1,1])
C0243095 (UMLS CUI [1,2])
C0031809 (UMLS CUI [1,3])
C0846574 (UMLS CUI [2,1])
C0243095 (UMLS CUI [2,2])

Lymph nodes

Item

Lymphknoten

boolean

C0024204 (UMLS CUI [1,1])
C0243095 (UMLS CUI [1,2])
C0031809 (UMLS CUI [1,3])

Lymph nodes (specification)

Item

Lymphknoten (wenn ja, bitte beschreiben)

text

C0024204 (UMLS CUI [1,1])
C0243095 (UMLS CUI [1,2])
C0031809 (UMLS CUI [1,3])

Other

Item

Sonstiges

boolean

C0205394 (UMLS CUI [1,1])
C0243095 (UMLS CUI [1,2])
C0031809 (UMLS CUI [1,3])

Other (specification)

Item

Sonstiges (wenn ja, bitte beschreiben)

text

C0205394 (UMLS CUI [1,1])
C0243095 (UMLS CUI [1,2])
C0031809 (UMLS CUI [1,3])

Wound

Item

Wunde

boolean

C0043250 (UMLS CUI [1,1])
C0243095 (UMLS CUI [1,2])
C0031809 (UMLS CUI [1,3])

Wound (specification)

Item

Wunde (wenn ja, bitte beschreiben)

text

C0043250 (UMLS CUI [1,1])
C0243095 (UMLS CUI [1,2])
C0031809 (UMLS CUI [1,3])

Sonography of transplanted kidney

Item Group

Transplantatsonographie

C2456887 (UMLS CUI-1)
C0022671 (UMLS CUI-3)

Morphology (qualitative)

Item

Morphologie (qualitativ)

text

C0332437 (UMLS CUI [1,1])
C0022646 (UMLS CUI [1,2])
C2456887 (UMLS CUI [2])

Longitudinal diameter

Item

Längsdurchmesser

integer

C1301886 (UMLS CUI [1,1])
C0022646 (UMLS CUI [1,2])
C2456887 (UMLS CUI [2])

Lateral diameter

Item

Querdurchmesser

integer

C1301886 (UMLS CUI [1,1])
C0022646 (UMLS CUI [1,2])
C2456887 (UMLS CUI [2])

Width of parenchyma

Item

Parenchymbreite

integer

C0227628 (UMLS CUI [1,1])
C0487742 (UMLS CUI [1,2])
C2456887 (UMLS CUI [2])

Doppler/Duplex sonography

Item

Doppler/Duplexsonographie

text

C0162481 (UMLS CUI [1,1])
C0022646 (UMLS CUI [1,2])
C2456887 (UMLS CUI [2])

Resistive index

Item

Resistenzindex

text

C0807745 (UMLS CUI [1,1])
C0022646 (UMLS CUI [1,2])
C2456887 (UMLS CUI [2])

Renal arteries Vmax

Item

Nierenarterien Vmax

integer

C0035065 (UMLS CUI [1,1])
C1710637 (UMLS CUI [1,2])
C0022646 (UMLS CUI [1,3])
C2456887 (UMLS CUI [2])

Quality of flow in renal artery

Item

Flowqualität in der Nierenarterie

text

C0035065 (UMLS CUI [1,1])
C0232338 (UMLS CUI [1,2])
C0022646 (UMLS CUI [1,3])
C2456887 (UMLS CUI [2])

Other

Item

Sonstiges

text

C0205394 (UMLS CUI [1,1])
C2456887 (UMLS CUI [1,2])
C0022671 (UMLS CUI [1,3])

Summary/Procedure

Item Group

Zusammenfassung/Procedere

C0087111 (UMLS CUI-1)
C0242482 (UMLS CUI-2)

Procedure

Item

Procedere

text

C0087111 (UMLS CUI [1])

Summary of medical history

Item

Zusammenfassung Anamnese

text

C0242482 (UMLS CUI [1,1])
C0262926 (UMLS CUI [1,2])

Summary of clinical examination

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Zusammenfassung klinische Untersuchung

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C0242482 (UMLS CUI [1,1])
C0031809 (UMLS CUI [1,2])

Summary of sonography

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Zusammenfassung Sonographie

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C0242482 (UMLS CUI [1,1])
C2456887 (UMLS CUI [1,2])
C0022671 (UMLS CUI [1,3])

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AN MS MEDD Anamnese KU NTX University Hospital Muenster (UKM) Subform

AN MS MEDD Anamnese KU NTX University Hospital Muenster (UKM) Subform

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